Objectives. At the end of the presentation we will be able to:

Transcription

1

2 Objectives At the end of the presentation we will be able to: Describe the primary functions and the nature of care in an Ebola Treatment Unit (ETU) in Liberia, Adapt lessons from West Africa to preparations for patients with Ebola Virus Disease (EVD) in a United States hospital. Disclosures: I am clinical in my hospital & operational in the field. I have derived only financial burden through my endeavors related to this illness.

3 An Introduction Video by Ben C. Solomon for the New York Times

4 My Experience Volunteer Medical Coordinator with International Medical Corps Sept. 23 rd Oct. 23 rd, 2014 Bong County, Liberia Roughly 130 suspected & confirmed cases

5 Bong County, Liberia

6 The Bong ETU NYTimes map of the ETU

7 ETU Priorities Community Outreach Survivor Support Break the Chain Patient Care Safe Patient Transit Staff Safety

8 Triage Contact? Fever, bleeding, or unexplained death? 3 or more symptoms: Malaise, anorexia, myalgias, arthritis, sore throat, SOB, n/v/d, hiccups, headache, or conjunctivitis

9 Triage

10 Testing http///phil.cdc.gov/phil/details.asp

11 Patient Treatment Supportive Measures Fluids Anti-emetics Analgesia Sedation Anti-psychotics Empiric Anti-infectives Malaria Antibiotic Photo: Daniel Berehulak for The New York Times

12 Fluids O. R. S. Adults: 1.5 liters/day + Peds 50 cc/kg/day+ Lactated Ringers Adults: 1-2 liter bolus Peds: 30 cc/kg bolus may be repeated

13 What We Weren t Using Convalescent Serum Transfusion Antivirals Pooled antibodies Weird experimentation

14 What Causes the Deaths Hypovolemic shock? Critically low K +, Mag, or Ca ++? Hemorrhage? Multi-organ system failure? Secondary infection? Photo: Daniel Berehulak for The New York Times

15 Infection Control PPE is only the start Facility structure & layout Structured movement: patients, staff, & materials WaSH: chlorinated water, sprayers, & waste management Vigilance, checklists, & mutual responsibility

16 Translate to U.S. Hospitals West Africa United States Purpose-built, single use facilities Austere conditions & supply chains Limited testing & treatment modalities Existing facilities Complex regulatory milieu Advanced diagnostics & treatment Very few cases Many cases

17 The Same Priorities Community Outreach Survivor Support Break the Chain Patient Care Safe Patient Transit Staff Safety

18 Hazard & Vulnerability Earthquakes!!! A mixture of infrastructure/it issues Mass Casualty Trauma Supply chain disruption Epidemic/Pandemic 2009

19 A Complex Regulatory Milieu The Joint Commission Disaster preparedness Infection Control OSHA (>35) Cal-OSHA NIOSH Union contracts Accessed on March 20, 2015 at:

20 Guidance & Standards

21 Guidance & Standards (cont.) Center for Medicare & Medicaid Services Hospitals Strongly urged to accept CDC guidance EMTALA & Ebola Screening, isolation, & stabilization General disaster standards anticipated

22 Hospital Preparedness Patient isolation Location & movement Peds, L&D Treatment team (volunteer) PPE Training & simulation Materials management Lab services Waste management Internal/external communications Family services Hospital Incident Command System

23 Structured Treatment Team Small efficient, volunteer teams Consultants will not likely enter a high-risk area Intensive training with the PPE, infection control plan, & approach to patient care Dedicated equipment & materials management Goal: Minimize the potential number of contacts while providing optimal care

24 An Example of U.S. PPE Multiple iterations Evolving guidelines Simulation center 140+ trained Costs?

25 Testing (In-house) Microbiology & virology Blood cultures held in plastic bottles Other specimens after Ebola (-) Chemistries/Point of Care: Electrolytes, lactate, H/H, INR, blood gas Malaria, pregnancy Hematology: separate area of the main lab?

26 Other Considerations? Malaria Typhoid fever Yellow fever Other hemorrhagic fevers: o Lassa, Marburg or Crimean-Congo Measles Dengue Chikungunya H. influenzae type B African trypanosomiasis Shigella Dengue Varicella Pneumococcus Meningococcemia Leptospirosis Influenza Tuberculosis HIV Hepatitis A & B Rabies

27 Treatment PICC lines Continuous infusions, TPN, & pressors Transfusions Mechanical Ventilation Hemodialysis Experimental antivirals

28 In Ebola Work as a team No emergency trumps infection control

29 Virus of the Year? MERS-CoV? Enterovirus D68? Mismatched influenza? Measles? Ebola? Zombie Apocalypse?

30 SARS Io M Report Ontario Provincial Report Spring of Fear Public health, law, economics Respiratory v contact Toronto v Vancouver Infection control

31 Learn & Pivot Johns Hopkins PPE: Beautiful & close Expand the operational requirements Specify in the regulatory guidance Accessed on March 6, 2015 at: Economies of scale

32 Early in a Wildland Fire Great Northern Type II Initial Attack With thanks to the Flathead Hotshots

33 Mop Up After complete containment Strenuous & unglamorous Essential Precedes rehab & recovery Accessed February 26, 2015 at /photograph/3424/23/

34 In Summary We can safely treat patients with Ebola in West Africa, & successfully disrupt the chain of transmission. The lessons from West Africa & prior outbreaks can improve preparedness in the U.S. With foresight, these same lessons may be adapted to future emerging infections.

35 Acknowledgements Gina & Mateo Stanford Health Care The survivors, communities, & those who continue this fight in West Africa